Business Analyst Healthcare

KHUSHBU PATEL

Lead Healthcare Business Analyst Claims & EDI Analyst

Evans, GA ****************@*****.*** 803-***-****

Professional Summary

Results-driven Healthcare Business Analyst with 7 years of progressive experience across payer-provider data exchanges, EDI integration, claims adjudication, and compliance-driven business transformation. Adept at bridging the gap between cross-functional stakeholders, healthcare systems, and IT teams to drive regulatory adherence, reduce operational waste, and enhance care coordination through data.

Subject matter expert in healthcare EDI transactions including 837 (Institutional/Professional Claims), 835 (Remittance Advice), 834 (Benefit Enrollment), and 270/271 (Eligibility Inquiry/Response), ensuring end-to-end lifecycle compliance.

Proficient in querying and optimizing datasets using SQL, SSIS, and data visualization tools such as Tableau and Power BI for analytics, utilization trends, and performance dashboards.

Functional experience with payer core admin platforms including Facets, QNXT, and Epic Tapestry, with hands-on configuration for claims routing and benefit plan setups.

Strong understanding of HIPAA 5010, ICD-10, CPT/HCPCS, HL7, CMS regulations, and Affordable Care Act mandates, including impact assessments and compliance testing.

Delivered system migration projects from legacy environments to modern cloud-based claims engines, ensuring data integrity and minimal disruption during rollouts.

Spearheaded automation efforts using scripting and RPA to eliminate manual intervention in claims validation, achieving a 40% reduction in cycle time.

Led Joint Application Development (JAD) sessions and stakeholder workshops to drive consensus on BRDs and functional designs, improving requirement traceability.

Successfully managed third-party vendor integrations and clearinghouse collaborations (e.g., Availity, Change Healthcare), enhancing real-time transaction throughput and reducing rejection rates.

Conducted UAT, system, and regression testing aligned with healthcare scenarios, building detailed test cases and leveraging ALM tools like Jira and HP ALM.

Strong interpersonal communicator with proven ability to collaborate with clinical staff, IT developers, QA teams, and compliance officers to ensure project alignment and delivery success.

Technical Skills

Healthcare Systems

Facets, QNXT, EPIC, MedicaSoft, HealthEdge

EDI Transactions

837I, 837P, 837D, 835, 270/271, 276/277, 278, 834

Regulatory Compliance

HIPAA 5010, CMS, ICD-10, CPT, HL7, ACA, NCPDP

Database & SQL

SQL Server, PostgreSQL, MySQL, SSIS, SSRS

Testing & QA

UAT, SIT, HP ALM, JIRA, Postman, SoapUI

Project Management

Agile (Scrum/Kanban), Waterfall, JIRA, Confluence

BI & Reporting

Power BI, Tableau, Excel Pivot Tables

Professional Experience

Lead Healthcare Business Analyst

Quartz Health Solutions Remote GA May 2023 – Present

Serving as a Lead Healthcare Business Analyst, I was responsible for driving the end-to-end analysis, functional documentation, stakeholder alignment, and testing efforts related to healthcare claims transactions and payer-provider data exchanges. My role bridged clinical operations, IT, and compliance to ensure the successful delivery of the automation framework and optimized EDI processes.

Key Responsibilities:

Translated business goals into detailed requirements for 837 (Claims), 835 (Remittance), and 270/271 (Eligibility) EDI transactions, improving claim lifecycle transparency.

Analyzed historical claim rejection patterns and configured validation rules that led to a 25% drop in denial rates within six months of go-live.

Designed and executed SQL queries to extract, validate, and monitor claims data for anomalies, enabling proactive resolution of systemic issues.

Collaborated cross-functionally with IT architects and finance leads to overhaul the EDI interface layer, enhancing data exchange accuracy and throughput.

Spearheaded UAT and SIT cycles for claims adjudication rules, creating test cases and coordinating test execution with QA teams using Jira.

Introduced automated error logging and real-time alerts for failed EDI transactions, reducing manual triage and enhancing audit readiness.

Conducted JAD sessions with business units and SMEs to finalize solution scope and drive consensus on BRD/FRD sign-offs.

Delivered training workshops to business users on interpreting EDI 835 remittance advice reports and troubleshooting common rejection codes.

Managed third-party clearinghouse integration (Change Healthcare), reducing EDI transmission delays and increasing first-pass claim acceptance rates.

Ensured full HIPAA 5010 and CMS regulatory compliance through traceable documentation, internal audits, and alignment with Medicaid/Medicare processing guidelines.

Tools/Environment: Facets, SQL Server, Tableau, HIPAA 5010, QNXT, ANSI X12, CMS, EDI 837/835/270/271

Healthcare Business Analyst

Priority Health Grand Rapids, MI July 2020 – April 2023

As a Healthcare Business Analyst, I played a pivotal role in defining future-state EDI workflows, managing the migration roadmap, and bridging cross-functional stakeholders across IT, compliance, and operations. I owned the requirements lifecycle, data analytics, and testing oversight for core EDI transactions.

Key Responsibilities:

Defined and documented new business rules and process flows for 837 (Institutional & Professional Claims), 835 (Remittance), and 270/271 (Eligibility), aligning with payer-specific adjudication logic.

Performed extensive gap analysis between legacy systems and the target-state EDI hub, identifying automation opportunities that led to a 20% improvement in claims auto-adjudication.

Authored complex SQL queries to analyze high-volume transaction data, pinpoint root causes of rejections, and track downstream financial variances.

Partnered with system integrators to successfully migrate over 1 million active eligibility and claims records to the new BizTalk-driven EDI platform with zero data loss.

Designed and executed UAT scenarios simulating real-world provider submission errors, contributing to system robustness and fewer post-go-live issues.

Facilitated alignment across compliance, clinical, and IT teams through targeted stakeholder meetings, ensuring solution designs met both technical and regulatory needs.

Developed detailed EDI mapping documentation and user guides to accelerate onboarding of claims staff and reduce the learning curve.

Interpreted new CMS and state Medicaid compliance standards and incorporated those into the transaction validation layer to ensure regulatory adherence.

Managed clearinghouse data exchange improvements in collaboration with Availity and payer IT teams, boosting claims acknowledgment timeliness.

Built Power BI dashboards for C-suite stakeholders to visualize KPIs such as average adjudication time, top rejection codes, and financial impact metrics.

Tools/Environment: BizTalk, SQL Server, Power BI, HIPAA 5010, ANSI X12, Medicaid, 837/835/270/271

Business Analyst

AmTrust Financial Services Cleveland, OH Jan 2018 – June 2020

As a Business Analyst embedded in the enterprise transformation office, I led business process re-engineering, collaborated with underwriting and actuarial teams, and served as the liaison between IT and business units. My focus was to ensure the delivery of a scalable, compliant, and automation-ready policy underwriting solution.

Key Responsibilities:

Collected and documented detailed business requirements for commercial and personal lines underwriting, risk evaluation, and claims alignment.

Conducted process gap analysis and mapped “as-is” vs. “to-be” workflows using BPMN and UML techniques, identifying automation opportunities.

Built use cases, business rules, and process flows that directly informed platform configuration and helped reduce underwriting turnaround times.

Developed SQL-based analytics for underwriting insights—enabling actuaries to assess policyholder behavior and adjust premiums dynamically.

Partnered with IT architects to ensure smooth integration between the new underwriting platform and legacy claims management systems, minimizing data silos.

Supported UAT phases by validating business logic, performing data reconciliation, and ensuring all rules were functioning within compliance boundaries.

Designed user-friendly policyholder self-service modules (quote, renewals, endorsements), reducing service center inquiries by over 30%.

Provided regulatory guidance on SOX and IFRS 17 implications, ensuring auditability and global compliance.

Facilitated JAD workshops with underwriters, actuaries, and developers to ensure technical feasibility and business alignment.

Trained insurance agents on new policy system features, improving platform adoption and reducing errors in risk submissions.

Tools/Environment: SQL Server, Power BI, JIRA, Agile, Visio, UML/BPMN, SOX

EDUCATION

Bachelor’s degree in Computer Science

Silver Oak College of Science & Technology, India

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